Interprofessional communication in medical simulation: findings from a scoping review and implications for academic medicine

Background Interprofessional communication is fundamental to the delivery of healthcare and can be taught in medical school and other health professional schools through interprofessional education (IPE) activities. Simulation centers have become a predominant location for simulation IPE activities with infrastructure able to support high fidelity activities in a controlled environment. In this secondary analysis of a scoping review conducted on simulation-based IPE, we describe the characteristics of previously reported simulation IPE activities involving undergraduate medical students in a simulation center focused on interprofessional communication. Methods Electronic searches of PubMed, CINAHL, and ERIC databases in accordance with PRISMA-ScR guidelines were conducted to isolate relevant articles from 2016–2020. In total, 165 peer-reviewed articles met inclusion criteria and data extraction linked to four research questions was applied by one individual and the accuracy was confirmed by a second individual. A secondary analysis was performed to describe what existing approaches for simulation IPE in simulation center settings have been used to explicitly achieve interprofessional communication competencies in undergraduate medical education. A sub-dataset was developed from the original scoping review and identified 21 studies describing simulation IPE activities that took place in dedicated simulation centers, targeted the IPEC interprofessional communication domain, and involved undergraduate medical students. Results Though diverse, the majority of simulation IPE activities described high-fidelity approaches involving standardized patients and utilized assessment tools with established validity evidence in IPE activities to measure learning outcomes. A minority of simulation IPE activities were described as hybrid and utilized more than one resource or equipment for the activity and only two were longitudinal in nature. Learning outcomes were focused predominantly on modification of attitudes/perceptions and few targeted higher levels of assessment. Conclusions Educators charged with developing simulation IPE activities for medical students focused on interprofessional communication should incorporate assessment tools that have validity evidence from similar activities, target higher level learning outcomes, and leverage hybrid models to develop longitudinal simulation IPE activities. Though an ideal environment to achieve higher level learning outcomes, simulation centers are not required for meaningful simulation IPE activities. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-022-03226-9.


Introduction
is defined as "the degree to which the simulation replicates the real event and/or workplace; this includes physical, psychological, and environmental elements" [29]. High-fidelity simulation refers to extremely realistic simulation experiences that provide a high level of interactivity and realism for the health professionals [29,30]. Simulation centers are widespread and growing in health professions education, providing an opportunity to develop large-scale IPE simulations that involve an optimized number and combination of students at the appropriate level of training for interprofessional practice [24,31,32]. These settings, also referred to as clinical skills centers, are commonly used as a location for high-fidelity simulation specifically with SPs and SP training programs, leveraging dedicated staff and examination rooms in a controlled environment in medical education [33,34]. The Association of American Medical Colleges reports that increased activities for medical students in a simulation center result in increased repetitive opportunities for learning clinical skills and assessment throughout the medical curriculum [35]. Simulation centers have been used to develop early interprofessional teamwork and communication skills in medical and nursing students which may possibly affect professional practice and subsequent patient safety [24].
Despite growing expectations across health professions education for longitudinal IPE, IPE activities occur most frequently as single events, thus limiting the goals of modifying health professionals' behaviors and potentially improving patient outcomes [14,15,36]. The importance of longitudinal studies, commonly defined as taking place over at least one year, has been recognized [37]. Longitudinal IPE studies have shown improvement in perceptions and skills amongst health professional learners but are lacking in number [36,[38][39][40].
The introduction of interprofessional communication in simulation activities in undergraduate medical education may lead to improved interprofessional communication beyond medical education, though further descriptions of these simulation activities is needed. In this secondary analysis of a scoping review conducted on simulation-based IPE, we aimed to determine the characteristics of previously reported simulation IPE activities involving undergraduate medical students in a simulation center that explicitly identified increasing competence in interprofessional communication as a desired outcome. We sought to identify co-learners, other targeted IPEC competencies, and intended learning outcomes using the Kirkpatrick's Expanded Outcomes Typology [41]. We also sought to compile practical considerations reported by authors, including barriers to successful execution.

Methods
A complete description of our scoping review protocol, conducted in accordance with JBI guidelines for scoping reviews (i.e., PRISMA-ScR), has been previously published [42]. In summary, we searched PubMed directly and used the EBSCO platform to search CINAHL Plus and ERIC databases with results limited to the year 2016. Our scoping review was designed to inform the following research questions: In what contexts has simulation IPE been implemented, in regard to learner type, setting, topics, level of fidelity, and resources used? Which IPEC competencies for interprofessional collaborative practice have been included in the design of simulation IPE? What student learning, educator-related, and patientrelated outcomes have been measured and reported in the design of simulation IPE? What are the facilitators and barriers to simulation IPE?
These research questions were intentionally broad in order to gather a general and expansive view of the literature. Inclusion criteria included study participants, concept, context and types of data sources. Studies published in peer-reviewed literature that reported on simulation activities involving two or more types of undergraduate or graduate health professional learners in the simulation environment that were delivered in academic settings, clinical settings, community settings, or other settings and included either quantitative, qualitative, or mixed methods were included.
In total, 165 peer-reviewed articles met inclusion criteria, and a 31-item data extraction tool linked to our four research questions was applied. The complete data extraction tool has been previously published with the protocol; examples of data extracted included types of learners (by profession), settings, IPEC competencies targeted, learning outcomes, and reported assessment/ evaluation strategies [42]. Data extraction was completed by an individual team member. A second team member independently reviewed and confirmed the accuracy of extracted data. Identified discrepancies were resolved by these individuals with a third team member available to adjudicate unresolved discrepancies.
Kirkpatrick's Expanded Outcomes Typology was used to categorize learning outcomes, commonly utilized in educational training and simulation as a method of evaluating and categorizing outcome criteria of educational training [41,43,44]. Kirkpatrick's original four-level model classifies learning into reaction, learning, behavior, and results [44]. This was later expanded with an explicit aim of application to IPE, as a mechanism to demonstrate the opportunities for IPE across the learning continuum as learners move from preclinical curricula and clinical learning environments into practice. The Kirkpatrick model includes levels and sublevels [41,45]: Additional research questions were developed to guide secondary analyses of the complete scoping review dataset. This secondary analysis was conceived to inform strategies to address LCME accreditation requirements and was organized around the following research question: What existing approaches for simulation IPE in simulation center settings have been used to explicitly achieve interprofessional communication competencies in undergraduate medical education? Guided by this question, a sub-dataset was developed from the original by identifying studies describing simulation IPE activities that (1) took place in dedicated simulation centers, (2) targeted the IPEC interprofessional communication domain, and (3) involved undergraduate medical students.

Results
Of the 165 articles that met inclusion criteria for our scoping review, 144 were excluded from the secondary analysis because they did not meet all three criteria; therefore, 21 articles published between 2016-2020 were included (Table 1). Simulation IPE activities covered a variety of topics, including mental health, cardiovascular health, oral health, medication errors, end-of-life care, discharge planning, inpatient and outpatient care, transitions of care, and emergency care. The majority of simulation IPE activities were categorized as high-fidelity (76%, 16/21). Standardized patients were utilized in 71% (15/21) of activities; 29% (6/21) utilized mannikins only. Thirty-three percent (7/21) were categorized as hybrid activities, utilizing more than one resource or equipment for the activity, to include virtual reality, mannikins, simulated health records, and SPs. Ten percent (2/21) were longitudinal simulation IPE activities. Medical students most commonly worked with nursing students (undergraduate and graduate) in identified simulation IPE activities (90%, 19/21), followed by pharmacy students (43%, 9/21). Less commonly reported were partnerships with occupational therapy and physical therapy (19%, 4/21); dentistry and dietetics/nutrition (each 14%, 3/21); physician assistant, social work, and speech language pathology (each 10%, 2/21); midwifery, operating department practitioner, psychology, public health, and respiratory therapy (each 5%, 1/21).
Author-reported challenges included scheduling limitations when combining different health professional learners, time demands on faculty, geographic challenges due to different school locations, technologic complications with online activities, and lack of control groups to facilitate comparative analyses. Mismatches in learner cohort sizes resulted in disproportionate numbers of one type of learner compared to another in several simulation IPE activities, as well as mismatches of different types of learners according to learning level (e.g., novice, intermediate, advanced).

Discussion
In this study, we found significant variability in terms of health-related topics taught and instruction methods employed during simulation IPE activities focused on interprofessional communication in simulation centers. However, high-fidelity simulations emerged as a predominant method of instruction, with the majority utilizing SPs. Standardized patients are considered the highest fidelity simulators and are used frequently to teach communication and interpersonal skills within undergraduate health professional curricula to improve transfer to the clinical learning environment [67,68]. Standardized patients provide a clear benefit over role play in an authentic, yet 'safe' first experience in clinical interactions, while also providing professional feedback from the perspective of the patient [26,[69][70][71]. Performance  22:204 feedback from SPs is considered a reliable source for assessing communication skills in educational programs [69,71,72]. Standardized patients are frequently used to increase the fidelity of interprofessional communication-focused simulation IPE activities, consistent with our findings. The addition of SPs can further increase the fidelity of simulation activities that do not currently utilize them; however, costs associated with utilizing SPs can be a limitation [26,70].
We limited our focus to simulation IPE activities that were located in simulation centers based on the assumption that characteristics common to this setting -controlled environment, skilled staff, SPs, mannikins, and robust infrastructure/equipment -would inform efforts to target higher-level learning outcomes along the Kirkpatrick continuum. Interestingly, our results demonstrated that most simulation IPE targeted lower-level learning outcomes despite taking place in simulation centers. Furthermore, we postulate that 62% (13/21) of the simulation IPE activities identified in our study can be completed outside of a simulation center; thus, many of these simulation IPE activities can likely be transferred to classroom, hospital, or clinic settings.
Another interesting finding from our study is the identified lack of simulation IPE developed to span the entire continuum of Kirkpatrick levels (Fig. 1), with only 9.5% (2/21) of articles demonstrating this approach [55,56].
The authors of these studies note challenges associated with this approach, including cost, logistics, schedules, faculty availability, and location of learners. A recommendation for achieving success in simulation IPE based on these two studies includes ensuring diversification of the types of modalities and/or pedagogical strategies employed, such as using video, telephone, workshops, and online simulations. By diversifying modalities and strategies, higher-level learning outcomes can be achieved with lower fidelity simulation IPE activities and less resources. In addition, less physical space is required for the activity at one given time and may not need to be located in a simulation center. Including video, telephone, or online simulations also eliminates the need for students to be geographically localized together [55]. Bok et al. described the characteristics of prevailing interprofessional communication programs for medical students in a scoping review from 2000-2018, identifying the indications and content of the programs, what training and evaluation methods each program used with the outcomes, and challenges experienced in 73 articles [38]. A content and thematic analysis was performed and themes/categories related to each of the four levels of Miller's Clinical Assessment Framework/Pyramid were described [38,73]. We chose to characterize activities in our review using Kirkpatrick's model as it is used frequently in medical education and is recommended  [49-54, 57-61, 63-65] within consensus guidelines for quality IPE, though Kirkpatrick's Expanded Outcomes Typology has been compared to Miller's Pyramid [14,[74][75][76]. Similar to Bok et al., we found significant variability in the assessment of simulation IPE activities in our analysis, with the majority targeting learners' reactions and modification of attitudes/perceptions, both considered lower-level outcomes. In another review, Abu-Rish et al. reported on qualitative, quantitative, and mixed method IPE studies published over five years that focused on IPE skills and/ or competencies with an assessment of IPE effectiveness, which included 22 simulation IPE studies [36]. Abu-Rish et al. highlighted several similar patterns identified in our analysis; for example, assessments predominantly targeted lower-level learning outcomes and the majority of instructional designs featured one-time events [36].
Numerous IPE measurement tools, teamwork assessment tools, and simulation assessment tools used in activities identified in our review were utilized ( Table 2). These assessment tools have documented validity evidence in IPE assessment, though we recognize that the validity of the tool is dependent on the context [66]. Studies that utilized one of these tools aimed to measure the same outcome of the original study of validation, such as attitudes or IPEC competencies, but did not always use the same groups of learners or setting. Some tools assessed simulation by observation to include IPE competencies but were not specific to IPE competencies. Our analysis validates much of what Bok et al., Abu-Rish et al., and others have reported, but Bok et al. and Abu-Rish et al. found that few programs utilized tools with established validity evidence in the assessment, whereas we found that the majority of simulation IPE activities used tools with established validity evidence [27,36,38]. Other studies have found that there is a lack of simulation IPE that is assessed with tools with validity evidence [27]. Our findings differ while simultaneously highlighting that tools with prior validity evidence should be used in a similar context and should continue to undergo the process of validation, thus adding to the literature [66].
The dearth of longitudinal simulation IPE activities in our study is consistent with what others have observed [36]. Longitudinal IPE activities with longitudinal followup of outcomes have shown improved interprofessional skills, communication, performance, and behaviors [39,40,47,48]. More longitudinal IPE activities are needed in addition to longitudinal assessment to identify whether outcomes are long-term and if they ultimately lead to improved patient outcomes [36,38,47,48]. Also congruent with our results were the difficulties and barriers to simulation IPE activities identified by authors, such as scheduling, mismatches of students at various levels of training, and lack of funding, faculty, staff and administrative support [36]. We agree there is significant diversity in the structure/content, objectives, and assessment of simulation IPE activities centered around interprofessional communication for medical students and a longitudinal approach to developing these activities should be prioritized [36,38,39].
The combination of modalities such as online activities and use of mannikins, SPs, and virtual reality in simulation IPE activities were limited in our review, as well as in the review by Bok et al. [38]. Benefits to hybrid activities include the elimination of logistical and resource barriers in a hybrid model to improve access to successful IPE [55,62,77]. Combining modalities in a longitudinal simulation IPE approach would also allow for repeated IPE interactions between learners with less dependence on space and time constraints, which would provide more opportunities for longitudinal IPE activities [39]. Students exposed to multiple IPE experiences across different settings have reported an increased impact on knowledge, skills, and attitudes than a single isolated IPE activity [55,56,78,79]. By augmenting an SP encounter with a simulated electronic medical record review, for example, health professional learners can gain additional practical experience with added realism [62]. Our review documented the combined use of mannikins and SPs most frequently in hybrid activities; however, and importantly, we found that most of these hybrid IPE simulation could be completed outside of simulation centers and that they could be modified to attain higher-level learning outcomes along the Kirkpatrick continuum. IPE simulation activities should attempt to combine multiple teaching modalities for high-fidelity activities focused on interprofessional communication. In our analysis, health professional learners identify the need for effective interprofessional communication. Simulation IPE, regardless of the type of modality used, can be used effectively to improve interprofessional communication based on the intended learning outcome and this seems to be independent of the location of the simulation. Reising et al. demonstrated that interprofessional communication improves performance [47]. This knowledge, combined with our results, should motivate medical educators to develop simulation IPE activities aimed at improving medical students' capacity for team-based care through improved interprofessional communication [3,8,9,47]. Based on our findings and recommendations of the Health Professions Accreditors Collaborative and the National Academy of Medicine, we also recommend greater use of the Kirkpatrick Expanded Outcomes Typology to drive the design and assessment of longitudinal simulation IPE activities that target higher-level learning outcomes, such as skill acquisition and behavior change [14,41].

Conclusion
This secondary analysis of a scoping review identified 21 articles published after 2016 that described simulation IPE activities involving medical learners in a simulation center and focused on interprofessional communication. While differences across these articles emerged regarding healthcare topics addressed, assessment tools utilized, learning outcomes measured, IPEC competencies targeted, and the types and combinations of health professional learners involved, several commonalities were identified that are instructive for medical educators throughout the world. We can draw from these commonalities and from those few studies included that have responded to calls from the IPE community to develop longitudinal IPE activities. To strengthen IPE simulation focused on interprofessional communication, we recommend that medical educators deliberately incorporate (1) hybrid instructional methods to bypass logistic hurdles, (2) longitudinal approaches to achieve higher-level learning outcomes, and (3) assessment tools with established validity evidence to measure those outcomes. Informed by our findings, this strategy will improve the skills and teamwork behaviors of medical students to improve patient care and outcomes.